Usually merged w/ the cardiac exam to cover DDx's, thus rarely performed in isolation
When do you want to assess the breathing system?
So when there's some sort of breathing symptom, like finding it difficult to breathe, coughing, or chest pain. If we find some previous problem with the lung. We rarely do the whole exam, because it takes so long And we usually merge it with the heart exam, to exclude certain alternatives we may be thinking.
Clubbing via Schamroth's window test, of interstitial lung disease
Tar staining, of smoking
Resistance test, of weakness and wasting. This involves asking the patient to move their fingers against your fingers, or towards your fingers
Peripheral cyanosis, of hypoxia
Flapping tremor, of carbon dioxide narcosis, asking patient to "put hands up, like a policeman doing a stop sign"
Pulse, including for the regularly irregular pulse of pulsus paradoxus
Subliminally counting for extreme respiratory rate, for of bradypnea and tachypnea
Ptosis eyelids of Horner's syndrome, of apical lung cancer
Central cyanosis, of hypoxia, asking patient to raise tongue to roof of mouth
Tracheal deviation, of deviation towards fibrosis, or deviation away from pleural effusion or pneumothorax. Note to patient this might feel a bit uncomfortable
Lymphadenopathy, starting to palpate at the top of the jaw line, moving towards and down the neck, to the supraclavicular area. Comment on having felt for postauricular nodes, submandibular nodes, cervivical nodes, and supraclavicular nodes, and that no lymphadenopathy could be felt
So the exam of the breathing system, we start with the hands?
Yep, so we look for clubbing, which can be seen in various diseases including interstitial lung disease. Tar staining, for smoking. Resistance test, for weakness and wasting. We move up to the palms, to look for blueness, of low oxygen. Moving up again, to the hands, to see if there's a flapping tremor, of carbon dioxide poisoning. Wrist, for pulse, including regularity, subliminally counting very slow or fast breathing rates.
Next to head?
Yep. So looking for drooping eyelids of Horner's syndrome, which we see in apical lung cancer. Central blueness, of low oxygen. We then move down to the trachea, to see if it's deviate, which it does TOWARDS dead tissue called fibrosis, or AWAY from air or fluid, such as a pleural effusion or pneumothorax. And lymph nodes, starting from behind the knees to above the clavicles.
Chest, starting from anterior, then posterior (remember "IPPA":
Inspection, asking patient to breathe out and in:
No evidence of breathlessness of COPD
No obvious wheeze of asthma, or stridor of inhaled objects
No obvious chest deformities or scars
Not evidently using his accessory muscles to breathe
Displaced apex beat, of moving towards the area of lung collapse (only on front)
Chest expansion, such as hyperexpansion of chest in COPD, by placing the thumbs together, and asking the patient to breathe out and in, and ensuring the fingers sufficiently move away from each other
Vocal fremitus, of pleural effusion, which is a palpable vibration on the body, found by asking the patient to repeat "999" (a low frequency vocalization), and feeling the patient's chest. It is indicative of friction
Percussion for the hyperresonance of pneumothorax, or the hyporesonance of consolidation, from top to bottom, on one side, then the other side, starting supraclavicular and going downwards (3x sets) (When doing the back, you must remember to ask patient to hug themselves, so you don't percuss their clavicle)
Ask patient to lift arm up, then percuss the two sides of the body (once on either side)
Listening for asymmetric and abnormal breath sounds of wheeze of asthma, stridor of inhaled objects, or crackles of pulmonary edema, asking patient to breathe normally, again starting supraclavicular, on either side, then going downwards (3x sets). Also doing the sides
Vocal resonance, of pleural effusion. It is again starting supraclavicular, on either side, 3 sets, but asking the patient to repeat "999" each time the stethescope is on the chest (only on back)
Bed side peak flow
Obs chart, paying particular attention to the temperature and oxygen sats
So now we go to the meaty part, the chest exam. How do we do that, and how do we memorize what we do?
So the mnemonic is IPPA, so inspection, palpation, percussion and auscultation. So we look for breathing type things, like breathlessness, wheeze, stridor, chest deformities, scars, use of accessory muscles. We feel for a displaced apex beat, which shifts towrds an area of lung collapse. We test for chesst expansion, specifically, when it super expands, in COPD. And vocal fremitus, where we can feel for a vibration when the patient talks, indicating friction. We then tap for a super loud sound when there's air in the lung called pneumothorax, or a super dull sound when there's water in the lung called consolidation. We then listen for asymmetric breath sounds, and abnormal breath sounds like wheeze of asthma, stridor of inhaled objects, or crackles of lung edema. And the listening version of vocal fremitus, called vocal resonance.
So to finish off we might want to take a look at the sputum pot. Have a look at the bed side peak flow, which shows the rate at which patients can blow air into a meter after a deep breath, over time. And the observation chart, which tells us the patient's vitals.